ABC of Emergency Radiology
THE ABDOMEN-II
D A Nicholson, P A Driscoll
Radiographic signs of trauma
Radiographic signs of splenic injury
Normal abdominal radiograph
Raised left hemidiaphragm
Left pleural effusion classic triad
Left basal atelectasis
Left lower rib fracture
Left upper quadrant mass and medial
displacement of gastric air bubble or
inferomedial displacement of splenic flexure
Splenic enlargement-usually with
subcapsular haemorrhage
Haemoperitoneum-see text
Splenic injury cannot be excluded by
a normal abdominal or chest
radiograph
Death after blunt abdominal trauma is
usually due to massive splenic or hepatic
haemorrhage-in such patients laparotomy
should not be delayed
Signs of retroperitoneal
haemorrhage
Bulging of lateral margin of psoas shadow
(bleeding confined by muscle fascia)
Obliteration of psoas shadow (free blood)
Cobliteationofvsoashe
Concave lumber
scolIosis
Loss of definition of renal outline
Ipsilateral fractures of lower ribs or lumbar
transverse processes
1410
Many of the disease processes that acutely affect the abdomen produce
radiographic signs, but most of these features are not specific for a particular
disease process or injury.
Blunt injuries
Clinical examination is notoriously difficult, and although an abdominal
radiograph can be taken as a first line investigation, often other imaging
methods such as ultrasonography and computed tomography are needed to
assess patients with multiple injuries who are haemodynamically stable and
therefore do not require urgent laparotomy.
Splenic injury-Splenic rupture is the most common serious injury
associated with blunt trauma in the upper abdomen. It may result in
subcapsular haemorrhage with an intact capsule or capsular disruption,
which is evident by intraperitoneal bleeding and haemorrhagic shock.
Blood usually accumulates in the left paracolic gutter, producing increased
soft tissue density between the descending colon and the properitoneal line.
A raised left hemidiaphragm should always be considered suspicious,
although this can occur normally.
Hepatic injury should be suspected in patients with a fracture of the right
lower rib. Concommitant splenic injury is reported in up to a quarter of
cases. A fifth show no signs or symptoms because the rupture is confined by
the capsule.
Intestinal injury-The small and large intestine are rarely damaged on
their own. Most patients have other more obvious injuries. Rupture of the
third part of duodenum is the most common site, with signs of
retroperitoneal haemorrhage or air surrounding the right kidney.
Penetrating injuries
Penetrating injuries resulting from high energy transfer are often so
severe that the patient's condition will not allow formal radiographic
studies. In haemodynamically stable patients, abdominal radiography is
valuable for localising foreign bodies and assessing associated skeletal or
soft tissue damage.
Abdominal gunshot wounds are a special problem in preoperative
evaluation. Renal function often needs to be assessed urgently to exclude
serious renal vascular damage. This can be done by taking an abdominal
~~~~~~~radiograph five minutes after giving intravenous iodinated contrast media.
BMJ VOLUME 307 27 NOVEMBER 1993
 t!:>~ .
Radiographic signs of the acute abdomen
ileus

The visibility of distended loops ofbowel depends on the air and fluid
content. Ileus can be generalised or localised to a segment of bowel after a
focallinflammatory process such as appendicitis, cholecystititis, or
pancreatitis. This gives rise to the sentinal loop sign.

Mechanical obstmction
Mechanical obstruction can be partial or complete, with the distribution
of distension depending on the site of obstruction.

Smafl bowel obstruction-Dilated small bowel loops are usually evident

FIG 1-Isolated,dilated Ip of duodenum in a
patient with acute pancreatitis (sentinel loop sign).
three to five hours after the onset of complete obstruction. They are
identified by their central distribution, the presence of close valvulae
conniventes that extend across the entire diameter ofthe bowel, and the
absence offaeces. As small bowel obstruction progresses the distal bowel
collapses and the colon becomes void of air. If the gut is largely fluid filled
small amounts of air collect in the recesses between the valvulae
conniventes, producing a chain of small radiolucent bubbles referred to as
the string of pearl sign. Distended loops that are almost completely filled
with fluid can be misinterpreted as ascites.

Large bowel obstruction-Dilated colon is identified by its peripheral

distribution, haustral sacculations (which are thick and extend only a short
distance into the gas filled lumen), and faecal content (fig 3). The
distribution of bowel gas and the risk of perforation depends on the
competency of the ileocaecal valve. With a competent valve the caecum is
most likely to perforate as it is the most compliant region ofthe large bowel
and distends more rapidly and to a greater degree than the remaining colon.
With an incompetent ileocaecal valve, the caecum is decompressed by air
passing into the small bowel. If the obstruction is complete and long
standing, the gastrointestinal tract will eventually decompensate and
become atonic as in ileus.

........

.... ...w.l

FIG 2-Complete small bowel obstruction due to

surgical adhesions. The stomach and proximal
1l'~ . ~....
..... ......
. . ....'..X.
small bowel are air filled and dilated. No gas is seen
in the large bowel.

P. .~ ~ ~ ~ ~ ...~ ~ -.~, ~ ~~ ~~ ~.~ ... . .

_r ...
~~~~~~~~~~~..

Causes of small bowel obstruction

Adhesions due to previous surgery (75%)
Strangulated hernias (10%)
Appendix abscess
Gall stone ileus (2%-commoner in women,
up to 25% in elderly patients)
Crohn's disease
Tumour
Intussusception
Volvulus
FIG -Large bowel obstruction due to obstructing
carcinoma in the descending colon. The large bowel is
dilated to the level of obstruction. No air is seen
distal to this in the sigmoid colon or rectum.

BMJ voLuME 307 27 NOVEMBER 1993 1411

 FIG 4-Pseudo-obstruction. Air is seen in the rectum
and throughout the dilated small and large bowel.
The caecum is massively distended to 15 cm and at
a high risk of perforation. No organic lesion was
found.
Commonest causes of large bowel
obstruction
Carcinoma (commonly sigmoid or
rectosigmoid)
Diverticular disease
Volvulus (10%)
FIG 6-Gall stone ileus showing multiple, dilated, air
filled loops of small bowel and gas in the biliary
tree (arrow). No air is seen in the large bowel,
suggesting small bowel obstruction.The gall stone is
often non-opaque or obscurred and therefore not
identified, as in this case.
1412
FIG 5-Classic appearance of sigmoid volvulus. The
volvulus appears as a dilated, folded loop of bowel
originating from the left side of the pelvis with a
coffee bean configuration.
Pseudo-obstruction mimics obstruction clinically and radiologically
but no obstructing lesion is found (fig 4). There-is diffuse dilatation of the
small and large bowel, often with prominent gastric distension. Barium
enema or flexible sigmoidoscopy are often needed to differentiate
pseudo-obstruction from organic obstruction.
Volvulus-Volvulus causes closed obstruction of loops, resulting in
both proximal and distal portions of a loop of bowel being completely
occluded. It occurs where the mesentery of the gut is longest, the most
common sites being the sigmoid colon and caecum. Volvulus of the
transverse colon and duodenum is rare.
In sigmoid volvulus there is a greatly dilated loop of colon, devoid of
haustra, arising from the left side of the pelvis and projecting obliquely
upwards to the right side of the abdomen. The volvulus overlies the
distended descending colon (left flank overlap sign) and inferior border of
liver (liver overlap sign). The central stripe is characteristic and is produced
by the adjacent walls of the upper and lower limb of the volvulus.
Even with severe distension in caecal volvulus two haustral markings
are usually identifiable. The left side ofthe colon is collapsed, but small bowel
dilatation is often clearly seen. In half of patients with caecal volvulus the
caecal pole inverts to lie in the left upper quadrant. In this orientation
the wall of the dilated caecum is often kidney shaped. In the other
half the twist is in the axial plane (without inversion) with the caecum
remaining in the right lower quadrant.
Gall stone ius-Gall stone ileus is the term given to mechanical
obstruction caused by a gall stone that has passed into the gastrointestinal
tract by eroding through the inflamed gall bladder wall (fig 6). The usual
site of impaction is the pelvic or terminal ileum. Specific radiological
signs are present in only 40%. These include gas in the biliary tree (30%),
partial or complete small bowel obstruction (50%), and visible ectopic
gall stone (35%).
BMJ VOLUME 307 27 NOVEMBER 1993
 Intussusception is most common in children under the age of 2 years and is
often due to lymphoid hyperplasia in the terminal ileum. Small bowel
obstruction is seen on the abdominal radiograph possibly with a soft tissue
mass surrounded by a crescent of air (fig 7).

Bowel ischaemia
The early radiological features of bowel ischaemia mimimc mechanical
obstruction but as the vascular occlusion progressesthe bowel wall becomes
oedematous and necrotic. This is seen as severe thickening of the bowel wall
associated with obstruction.

Ischaemic colitis most commonly affects the splenic flexure and

descending colon, with submucosal haemorrhage causing thickening of
the colonic wall. These changes are seen as thumb printing (fig 8).
Functional obstruction with dilatation of the proximal colon is commonly
seen. As the ischaemia progresses linear gas may be identified in the'bowel
wall, indicating necrosis. Free gas indicates perforation, and the presence
of gas in the portal vein is a serious prognostic sign.

FIG 7-Intussusception in an infant. There are

multiple dilated, air filled loops of bowel. The head
of the ileocaecal intussusceptus can be seen in the
region of the transverse colon, overlying the spine
(arrow).

Acute inflammatory colitis

The distribution of faecal material is a good
indicator of inflammation of the bowel wall.
In ulcerative colitis there is usually a sharp cut off
from normal bowel, which is identified by the
distal limit of the faecal residue (fig 9). With
extensive mucosal ulceration small normal
mucosal islands are left (pseudopolyps), which
can be seen on the plain film.

FIG 8-Ischaemic colitis of

the splenic flexure with
narrowing and severe
submucosal
haemorrhage in the distal
transverse colon (thumb
printing).
Occasionally a gasless colon is seen in a patient
with severe ulcerative colitis. When the
transverse colonic diameter exceeds 5-5 cm
megacolon should be diagnosed and when this is
associated with fever, tachycardia, leucocytosis,
and pain toxic megacolon exists. Perforation and
peritonitis are common sequelae (fig 10).

Acute pancreatitis
In most patients no plain film abnormality is
identified (fig 1). The signs most frequently seen,
however, are a dilated duodenal sentinal loop,
loss of the left psoas margin, signs of gastric
FIG s-Acute ulcerative outlet obstruction, and left sided pleural
colitis showing effusion. These features are non-specific.
oedematous left colon,
which is narrowed and
shortened. A cut off is
seen in the transverse
colon with faecal loading
of the right colon due to
functional obstruction.

BMJ voLuME 307 27 NOVEMBER 1993 1413

 Summary
Diagnostic quality
Alignment of bones
Bone margins and density
Cartilage and joints
Soft tissues
Bowel gas pattern
Pneumoperitoneum
Air in the biliary tree or portal vein
Size of organs
~~~~~~~~~~~~~~~ ..' ......: Fat-tissue interfaces
Abnormal calcification

D A Nicholson is consultant radiologist and P A Driscoll is

FIG lo-Erect chest radiograph showing a large senior lecturer in emergency medicine, Hope Hospital,
pneumoperitoneum with air under both diaphragms. The right Salford.
hemidiaphragm is raised. Dilated air filled loops of bowel are The ABC of Emergency Radiology has been edited by
projected overthe liver (arrows)-both sides ofthe bowel wall David Nicholson and Peter Driscoll.
can be seen (Rigler's sign).

Minimally Invasive Surgery

Treatment of urinary tract stones
J E A Wickham

This is the third in a series of
articles describing current
techniques in minimal access
surgery. The articles have
been written to inform
non-specialists of developments
in this rapidly moving subject.
Division of Minimally
Invasive Surgery,
Combined Medical and
Dental Schools of Guy's
and St Thomas' Hospital,
London
J E A Wickham, senior
research fellow
BMJ 1993;307:1414-7
Replacement of open surgery with minimally
invasive techniques for treating stones in the renal
tract has greatly reduced patients' morbidity and
mortality and the period of hospitalisation and
convalescence. Extracorporeal shockwave litho-
tripsy does not require anaesthesia and requires
little analgesia so that treatment can be given on an
outpatient basis, and there is no wound to heal. Only
a small puncture site is needed for percutaneous
endoscopic lithotomy, and with the advent of pro-
phylactic antibiotics there are few complications. Of
renal stones, about 85% can now be successfilly
treated by extracorporeal lithotripsy alone, and
almost all of the stones too large or hard for
lithotripsy can be treated endoscopically, with ultra-
sonic or electrohydraulic probes being used to
fragment the stone. Stones in the upper and lower
thirds of the ureter can be treated by extracorporeal
lithotripsy, but stones in the middle third, which
cannot normally be visualised to allow focusing of
the shockwaves, usually require ureteroscopy.
Nearly all bladder stones can be treated by trans-
urethral endoscopy with an electrohydraulic probe.
Only the largest renal tract stones still require open
surgery.
The renal stone
Ten years ago it was usual for a patient suffering
from a painful renal stone to undergo an open opera-
tion with a 25 cm loin incision to access the kidney.
Two hours of anaesthesia were followed by 10-14 days
in hospital, during which the patient would suffer
considerable pain and discomfort. The complications
of a major surgical intervention-bronchopneumonia,
pulmonary embolus, and wound infection-were not
unusual.' Six weeks' convalescence were necessary
before normal activities could be resumed.
PERCUTANEOUS ENDOSCOPIC LITHOTOMY
In 1979 at the Institute of Urology, London, and at
the University of Mainz, Germany, it was realised that
just as a percutaneous nephrostomy tube could be
inserted into the kidney under radiological control so it
might be possible to pass an endoscope down a tube
track to visualise a calculus and, if it was small, remove
it. In Germany this approach was initially restricted to
the removal of stones from tracks pre-established at
open surgery,2 while in London the first truly elective
endoscopic nephrolithotomies were performed and
reported in 1981.3 By 1983 several hundred patients
had been treated in Europe and the United States.47
The operation dramatically lessened patients'
morbidity and mortality but gave results as good as
those obtained by open surgery. Hospitalisation lasted
two to three days, and a return to full activity was
possible within a week. Analgesic requirements and
postoperative complications were much reduced."'0
The technique was refined, and larger stones of all
types were successfully treated with ultrasonic or
electrohydraulic disintegratory probes passed down
the endoscope.
Complications have largely been those of post-
operative septicaemia, presumably from the intro-
duction of infective material into open venous channels
in the kidney. When this was recognised appropriate
prophylactic antibiotics were introduced, and this has
become much less of a problem. Patients with coagulo-
pathies should not be treated by this technique since
considerable haemorrhage can result as in open
surgery. Venous bleeding may occur down the percu-
taneous tract, but this is easily tamponaded by insert-
ing a nephrostomy tube. Very rarely, arterial bleeding
from a segmental vessel may require selective emboli-
sation. Open retrieval surgery is almost unheard of for
control of bleeding.1' Few other complications have
been experienced.

1414 BMJ VOLUME 307 27NOVEMBER1993